Markers useful in enrichment strategies for treatment of osteoarthritis

Abstract

To provide pharmacogenetics, more specifically to strategies involving biomarkers associated with a clinical response to a compound before or during treatment of a cartilage disorder such as osteoarthritis.SOLUTION: The present invention more particularly relates to a combination of JSW measurements and a level of a specific protein present in the blood, serum, synovial fluid or urine, which can be used for adapting the treatment of a patient, in strategies such as patients' enrichment in clinical trials, patients' selection strategy before or during treatment or in a framework of treatments for cartilage disorder such as osteoarthritis.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] The present invention relates to pharmacogenetics, and more particularly to strategies involving markers associated with clinical response to compounds prior to or during the treatment of cartilage disorders such as osteoarthritis with said compounds. The present invention more particularly relates to the combination of Joint Space Width (JSW) measurements and levels of specific proteins present in blood, serum, synovial fluid or urine, which can be used in strategies such as enrichment of patients in clinical trials, patient selection strategies prior to or during treatment, or to adapt patient treatment in the context of the treatment of cartilage disorders such as osteoarthritis.

[0002] The present invention further discloses diagnostic tools and kits based on the combination of JSW measurements and the level of specific biomarkers.Therefore, the present invention can be used to predict the response to a compound for the treatment of cartilage disorders before or during the treatment.The strategies can be used to select / identify subjects to be treated by intra-articular administration of active compounds to treat cartilage disorders and in patient enrichment strategies.The use of these strategies, for example in diagnosis, can result in increased benefit and reduced risk in subjects. [Background technology]

[0003] Cartilage damage broadly refers to diseases characterized by abnormal metabolic degeneration in connective tissues, which manifests itself in pain, stiffness and limited movement of the affected body parts. These damages can be due to pathology or can be the result of trauma or injury. Cartilage damage includes osteoarthritis (OA), cartilage injury (including sports injuries of cartilage and joints, and surgical injuries such as microfractures), among others. Mature cartilage has limited ability to be repaired, especially because mature chondrocytes have little possibility of proliferation, and also due to the absence of blood vessels. In addition, cartilage is not well nitrified and has low oxygen pressure. Replacement of damaged cartilage, especially articular cartilage, caused by either injury or disease is a great challenge for physicians, and available surgical treatment procedures are considered not completely predictable and are only effective for a limited time. Therefore, the majority of young subjects do not seek treatment or are advised to postpone treatment as long as possible. When treatment is required, the standard procedure is age-dependent and varies between total joint replacement, implantation of small pieces of cartilage or marrow stimulation techniques (such as microfracture). Microfracture is a common procedure that involves penetration of the subchondral bone to stimulate cartilage deposition by bone marrow-derived stem cells. However, it has been shown that this technique does not adequately repair the cartilage defect and the new cartilage that is formed is mainly fibrocartilage, resulting in poor or altered function and biomechanics. Indeed, fibrocartilage does not have the same durability and may not adhere correctly to the surrounding hyaline cartilage. For this reason, the newly synthesized fibrocartilage may break down more easily (expected time frame: 5-10 years).

[0004] Non-surgical treatments for subjects with osteoarthritis consist of, among others, physical therapy, lifestyle modifications (e.g., increased physical activity), support devices, oral and injectable medications (e.g., nonsteroidal anti-inflammatory drugs), walking aids, and medical symptom management. If these treatments fail, surgery, such as joint replacement, becomes the main option for the subject. Tibial or femoral osteotomy (cutting of bone to rebalance joint wear) can reduce symptoms, help maintain an active lifestyle, and delay the need for total joint replacement. Total joint replacement can provide relief from symptoms of advanced osteoarthritis, but generally requires a change in the subject's lifestyle and / or activity level.

[0005] At the time, pharmacological treatments on the market are primarily targeted at pain relief. There are still no commercially available treatments that reverse or postpone cartilage damage (see Lotz, 2010).

[0006] Fibroblast growth factor 18 (FGF-18) is a member of the FGF family of proteins closely related to FGF-8 and FGF-17. FGF-18 has been shown to be a proliferative factor for chondrocytes and osteoblasts (Ellsworth et al., 2002; Shimoaka et al., 2002; Gigout et al., 2017). FGF-18 has been proposed for the treatment of cartilage disorders such as osteoarthritis and cartilage injury, either alone (WO 2008 / 023063) or in combination with hyaluronic acid (WO 2004 / 032849).

[0007] Sprifermin, a truncated form of human FGF-18, is being investigated in clinical trials for the treatment of both osteoarthritis and cartilage damage (see, e.g., NCT01033994, NCT00911469, and NCT01066871). The current dosing regimen for Sprifermin is once a week for three weeks (one treatment cycle), and the drug is administered via intra-articular injection. This treatment cycle can be repeated. This dosing regimen is described in WO 2008 / 023063.

[0008] At the time, OA and cartilage injury treatment with FGF-18 during clinical trials was provided to subjects without predictive information regarding response, i.e., without knowledge of the possibility that the treatment will be highly effective, moderately effective, or show only a slight effect or no effect (Lohmander et al., 2014; Dahlberg et al., 2016).Currently, a large population of treated subjects exhibits an intermediate / high response to treatment according to cartilage thickness and WOMAC score measured by MRI techniques after at least one treatment cycle with Sprifermin, while some others either do not respond to the treatment (i.e., no or limited increase in cartilage thickness measured by MRI) or respond with a higher WOMAC score compared to controls.

[0009] WO 2014 / 023703 describes a genetic marker (combination of SNPs IL-1RN rs9005 and IL-1RN rs315952) associated with the quality of clinical response to treatment of cartilage disorders such as OA, cartilage injury or microfractures with FGF-18. Such markers are useful for identifying, through pre-treatment genetic screening, subgroups of subjects more likely to exhibit a particular response to treatment with FGF-18, such as a very good clinical response to treatment with FGF-18, or conversely, subgroups of subjects for whom the therapy may fail.

[0010] Knowledge of the type of clinical response of a subject to treatment can be used to select or stratify patients for clinical trials, select therapy, optimize therapy, for example, select treatment with a compound as first-line therapy or adapt a dosing regimen.Such information is clinically useful for managing clinical trials or for medical management of cartilage disorders such as OA and / or cartilage injury in subjects.In addition, such predictive information can also be clinically useful for guiding decisions regarding dosing regimens.

[0011] In order to provide a full range of solutions for physicians seeking the best therapy for treated subjects or patients, there is a need to identify additional markers that aid in predicting placebo response and aid in clinical trial management, therapy optimization or therapy selection. Summary of the Invention

[0012] As described herein, metabolic biomarkers such as proC2 or CTX-II in combination with the physical marker JSW (joint space width) can be used in the detection, stratification, diagnosis and / or treatment of patients with osteoarthritis or cartilage disorders. The expression level (or amount) of at least one of these biomarkers (or a combination thereof) in combination with the physical marker JSW can be used, for example, to better classify patients or to detect patients who should be included in or conversely excluded from a particular therapy.

[0013] The present invention relates to a method for derisking in a clinical trial or determining a placebo effect in a clinical trial, said clinical trial relating to the treatment of cartilage disorders in a subject with an active compound, or during treatment with an active compound, comprising: a) measuring joint space width (JSW) in at least one knee of the subject; b) predicting the risk of placebo effect from the results of step a) The present invention is directed to a method, comprising:

[0014] According to the method, the presence of a JSW higher than 3.5±2 SD mm predicts a placebo effect. Conversely, the presence of a JSW lower than or equal to 3.5±2 SD mm predicts no or low placebo effect.

[0015] The present invention also provides a method of reducing risk in a clinical trial, the clinical trial involving the treatment of a cartilage disorder in a subject with an active compound, the method comprising: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; b) measuring the joint space width (JSW) in at least one knee of the subject; c) predicting the susceptibility of said subject to treatment with said active compound from the results of steps a) and b). wherein steps a) and b) are performed in any order; The method is targeted.

[0016] According to the method, the presence of a CTX-II higher than 350±2SDng / mmol or a ProC2 higher than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm predicts low or no sensitivity to treatment with an active compound. Conversely, the presence of 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW lower than or equal to 3.5±2SDmm, 2) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm, or 3) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL with a JSW lower than 3.5±2SDmm predicts sensitivity to treatment with an active compound.

[0017] 1. A method for selecting a subject having a cartilage disorder for treatment with an active compound or for inclusion in or exclusion from a clinical trial based on likely susceptibility to said treatment, comprising: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring the joint space width (JSW) in at least one knee of said subject, wherein the amount of at least one of these proteins and the width if the JSW are predictive of the subject's risk for being sensitive or insensitive to said treatment; and b) selecting susceptible subjects as suitable for said treatment or clinical trial. A method is also described, including:

[0018] According to the method, the presence of CTX-II higher than 350±2SDng / mmol or ProC2 higher than 4.2±2SDng / mL with JSW higher than 3.5±2SDmm preferably leads to the exclusion of the subject from treatment with the active compound. Conversely, the presence of 1) CTX-II lower than 350±2SDng / mmol and / or ProC2 lower than 4.2±2SDng / mL with JSW lower than or equal to 3.5±2SDmm, 2) CTX-II lower than 350±2SDng / mmol and / or ProC2 lower than 4.2±2SDng / mL with JSW higher than 3.5±2SDmm or 3) CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL with JSW lower than 3.5±2SDmm leads to the inclusion of the subject from treatment with the active compound.

[0019] Kits containing means for performing the methods according to the invention and instructions for use are also described.

[0020] Also encompassed is an active compound for use in the treatment of a subject with a cartilage disorder, characterized in that the subject exhibits 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW lower than or equal to 3.5±2SDmm, 2) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm, or 3) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL with a JSW lower than 3.5±2SDmm.

[0021] The present invention also provides a method of treating a subject having a cartilage disorder with an active compound, comprising the steps of: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring joint space width (JSW) in at least one knee of said subject, said amount and width being predictive with respect to the subject's risk for being susceptible to treatment with said active compound; b) Below: i. CTX-II lower than 350±2SDng / mmol and / or ProC2 lower than 4.2±2SDng / mL with JSW lower or equal to 3.5±2SDmm; ii. JSW greater than 3.5±2SDmm with CTX-II less than 350±2SDng / mmol and / or ProC2 less than 4.2±2SDng / mL; or iii. JSW lower than 3.5±2SDmm with CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL selecting an object having c) administering said active compound intra-articularly to said selected subject. Also of interest is a method, comprising: [Brief description of the drawings]

[0022] [Figure 1] Schematic of the dosing regimen used for FGF-18 compounds in the FORWARD study. [Diagram 2] Suggested enrichment strategies from the FDA draft guidance “Enrichment Strategies for Clinical Trials to Support Approval of Human Drugs and Biological Products” (FDA, 2012). [Diagram 3] Placebo response in KL2 and KL3 patients highlighted via total WOMAC score (i.e. placebo effect as a function of JSW). A) Group mean total WOMAC change from baseline in KL2 and KL3 groups as a function of time elapsed since the first IA injection as a function of time elapsed (data are mean + / - SD). B) Group mean total WOMAC score in KL2 and KL3 groups as a function of time elapsed since the first IA injection as a function of time elapsed (data are medians). [Figure 4] Placebo response as a function of biomarker levels highlighted via total WOMAC score. A) Total WOMAC change in groups as a function of time based on CTX-II levels (Group 1: ≦350 ng / mmol and Group 2: >350 ng / mmol) (data are mean + / - SD). B) Total WOMAC change in groups as a function of time based on ProC2 levels (Group 1: ≦4.2 ng / mmol and Group 2: >4.2 ng / mmol) (data are mean + / - SD). [Diagram 5] Placebo response combining both JSW measurments and CTX-II levels highlighted via group mean total WOMAC score as a function of time (months) elapsed. Data are taken from the placebo arm of a prospective study. [Figure 6-1]Figure 6A: Differences in the active arm versus the placebo arm as a function of the patient's KL grade and as a function of time since the first IA injection, as demonstrated using the total WOMAC score. Figure 6B: Differences in the active arm versus the placebo arm as a function of the patient's CTX-II level and as a function of time since the first IA injection, as demonstrated using the total WOMAC score. In Figures 6A-D, each group of treated patients (groups 2-5) from the prospective study was compared to the placebo group (group 1) (comparisons based on difference to placebo). Data are group medians. [Figure 6-2] Figure 6C: Differences of the active arm versus the placebo arm as a function of the patient's KL grade and as a function of time since the first IA injection, as demonstrated using cartilage thickness levels. Figure 6D: Differences of the active arm versus the placebo arm as a function of the patient's CTX-II level and as a function of time since the first IA injection, as demonstrated using cartilage thickness levels. In Figures 6A-D, each group of treated patients (groups 2-5) from the prospective study was compared to the placebo group (group 1) (comparisons based on difference to placebo). Data are group medians. [Figure 7] Placebo response combining both JSW (expressed as KL2 and KL3) and CTX-II levels highlighted via group mean (SEM) change in WOMAC pain scores as a function of time (months). The number of patients in each subgroup is as follows: n≈380 (KL2 with low CTX-II), n≈90 (KL2 with high CTX-II), n≈40 (KL3 with low CTX-II) and n≈20 (KL3 with high CTX-II). [Figure 8] Suggested enrichment strategies for any clinical trials in osteoarthritis based on the 2012 FDA draft guidance. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0023] In certain embodiments of the invention as a whole, i.e. in any of the methods or uses described herein, the subject has a cartilage disorder selected from the group consisting of osteoarthritis, cartilage injury, a fracture affecting articular cartilage or a surgical procedure having an impact on articular cartilage (e.g. microfracture), and the active compound may for example be selected from the group consisting of an FGF-18 compound, BMP-2, BMP-7, GDF-5, FGFβ, FGF-9, a SOX-9 enhancer, TGFβ, a Wnt inhibitor, an anti-MMP13 inhibitor, an anti-ADAMTS5 inhibitor, calcitonin and any variant or fusion protein thereof.

[0024] It should be understood that any method or use described herein requires obtaining a sample (or test sample) from the subject, for example via collection of blood, serum, synovial fluid or urine, before determining the amount of at least one of the proteins. Furthermore, it should also be understood that any method or use referred to herein is performed in vitro, not on an animal or human body.

[0025] definition - The term "FGF-18 compound" or "FGF-18", as used herein, is intended to be a protein that maintains at least one biological activity of wild-type human FGF-18 protein (e.g., increased osteogenic activity (see WO 98 / 1664) or chondrogenesis (see WO 2008 / 023063)). FGF-18 may be native (SEQ ID NO: 1), its mature form (corresponding to the amino acid sequence of SEQ ID NO: 1 from residue 28 (Glu) to residue 207 (Ala)), or a truncated form thereof, such as sprifermin (shown in SEQ ID NO: 2; having amino acid residues 2 to 170 of SEQ ID NO: 2 corresponding to amino acid residues 28 to 196 of SEQ ID NO: 1). The term "FGF-18 compound" also includes variants or mutants of native, mature, or truncated forms of FGF-18, as well as fusion proteins (such as those disclosed in the European Patent 17192467.3 patent family) that contain a (biologically) active FGF-18 portion linked to a heterologous protein or chemical compound. In such fusion proteins, the FGF-18 portion can be the native, mature, or truncated form of the FGF-18 protein or a variant or mutant thereof.

[0026] - The term "BMP-2" as used herein is a protein that plays an essential role in the differentiation of osteoprogenitor cells into osteoblasts, thus promoting bone and cartilage formation, in addition to inducing matrix synthesis and promoting cartilage repair (Deng et al., 2018). The full-length native form of human BMP-2 is represented in SEQ ID NO: 6. One recombinant form of the BMP-2 protein is known as dibothermin alpha. The term "BMP-2" also includes variants thereof, or fusion proteins that include a BMP-2 portion.

[0027] - The term "BMP-7" as used herein is a protein known for its osteogenic properties that has been shown to have a strong anabolic effect on cartilage by stimulating the synthesis of cartilage matrix components and increasing proteoglycan and collagen synthesis (Deng et al., 2018). The full-length native form of human BMP7 is represented in SEQ ID NO: 7. One recombinant form of the BMP-2 protein is known as eptotermin alpha. The term also includes variants thereof, or fusion proteins that include a BMP-7 portion.

[0028] - The term "GDF-5", also known as LAP-4 or radotermin, as used herein, is a protein that, among other things, has a stimulatory effect on matrix synthesis in human articular chondrocytes cultured in vitro from both healthy subjects and OA patients (Parrish et al., 2017). The full-length native form of human GDF-5 is represented in SEQ ID NO: 8. The term also includes variants thereof, or fusion proteins that include a GDF-5 portion.

[0029] - The term "FGFβ" or "FGF-2" as used herein is a protein known in cartilage repair. It has also been shown to stimulate chondrocyte proliferation in immature rabbits (Ameye and Young, 2006). The full-length native form of human FGF-2 is represented in SEQ ID NO: 9. One recombinant form of the FGFβ protein is known as trafermin. The term also includes variants thereof, or fusion proteins that include the FGFβ portion.

[0030] - The term "FGF-9" as used herein is a protein known to delay articular cartilage degradation in OA subjects, with a slightly negative impact on osteophyte formation (Zhou et al., 2016). The full-length native form of human FGF-9 is represented in SEQ ID NO: 10. The term also includes variants thereof, or fusion proteins that include an FGF-9 portion.

[0031] - The term "TGF-β" as used herein refers to the protein TGF-beta, which belongs to the TGF-beta family and has a crucial role in cartilage maintenance. TGF-beta has been shown to be a cartilage promoting factor (Wang 2014). The term also includes variants thereof or fusion proteins that contain a TGF-β portion.

[0032] - The term "SOX-9" enhancer, as used herein, is intended to mean a compound that enhances the production of SOX9. Indeed, SOX9 is a transcription factor that has been shown to be essential for cartilage extracellular matrix (ECM) formation.

[0033] - the term "calcitonin" as used herein refers to a 32 amino acid peptide (SEQ ID NO: 5), more particularly of the salmon calcitonin species, that has been demonstrated to have protective activity for both bone and cartilage.

[0034] - The term "Wnt inhibitor", as used herein, is intended to be a compound that interferes with the WNT pathway.

[0035] - The term "anti-MMP13 inhibitor" as used herein is intended to mean a compound that inhibits the activity of matrix metalloproteinase 13 (MMP13). MMP13 is one of the key collagen type II degrading enzymes.

[0036] - the term "anti-ADAMTS4 or 5 inhibitor", as used herein, is intended to be a compound that inhibits the enzymatic activity of a disintegrin and metalloproteinase with thrombospondin motifs 4 or 5 (ADAMTS4 or ADAMTS5).

[0037] - The terms "biomarker" or "protein marker" are used interchangeably. In the context of the present invention, they are peptides or proteins. A "prognostic biomarker" is one that gives information about the state of a subject, including but not limited to disease progression, disease severity or disease outcome, regardless of any therapy. A "predictive biomarker" is one that gives information about the effect of a given therapy, including but not limited to efficacy and safety outcomes. The definitions of prognostic and predictive are not mutually exclusive, so a biomarker can be both prognostic and predictive. The amount of a biomarker or the expression level of a biomarker is expressed herein as nmol, μmol, mmol, ng, μg, mg or g of a given protein. The amount or level can be expressed as an absolute value (e.g., 10 ng or 2 μg) or as a concentration (e.g., 10 ng / mL, 2 μg / mL, 10 ng / mmol or 2 μg / mmol).

[0038] - The term "metabolic biomarker" refers to biomarkers such as, but not limited to, CTX-II, ProC2, PIIANP, C2M, ARGS and AGNx1. More particularly, the term "metabolic biomarker" refers to biomarkers of cartilage metabolism, i.e. collagen and aggrecan turnover, e.g., degradation and / or synthesis of cartilage matrix components. Different collagen and aggrecan biomarkers have been described (Karsdal et al., 2016).

[0039] - The term "CTX-II" or "CTXII" refers to the C-terminal telopeptide of collagen type II. See SEQ ID NO: 1. It is a biomarker of collagen type II degradation, which is part of osteoarthritis (see, e.g., Duclos et al., 2010).

[0040] - The term proC2 refers to a collagen type II neo-epitope generated during collagen type II synthesis, which has the sequence QDVRQP recognized as an epitope in the proC2 assay, and ProC2 is a biomarker for chondrogenesis (type II collagen formation) assays. See SEQ ID NO: 2. ProC2 is associated with the capacity for repair and may be a valuable tool for identifying patients with cartilage-driven diseases. ProC2 is a biomarker that has been tested in preclinical studies of clinical samples (see, for example, Gudmann et al., 2016; Munk et al., 2016; Gudmann et al., 2014).

[0041] - The term PIIANP refers to the propeptide of collagen type II, type IIA procollagen contains an N-terminal 69 amino acid, cysteine-rich globular domain encoded by exon 2 of the collagen type II gene. Type IIA procollagen has been found to be synthesized by osteoarthritic chondrocytes in diseased cartilage and may serve as a unique arthritis biomarker reflecting attempts by chondrocytes to repair diseased cartilage (Valdes et al, 2014).

[0042] - The term C2M refers to serological type II collagen degradation neo-epitope linked to cartilage degradation. C2M is an interhelical fragment of type II collagen generated by MMPs. Biomarkers have been described that are associated with drug response, pain intensity and radiographic severity (Valdes et al. 2014).

[0043] - The term ARGS refers to neoepitopes generated during aggrecan degradation. The assay detects aggrecan degradation products in serum and synovial fluid. ARGS levels are linked to progression in cartilage damage (Struglics et al., 2011; Struglics et al., 2015).

[0044] - The term AGNx1 relates to an assay that detects another neo-epitope generated during aggrecan degradation.

[0045] With respect to biomarkers, the terms "amount" or "expression level" may be used interchangeably.

[0046] The term "physical marker" refers to joint space width (JSW) and its assessment in the context of the present invention.

[0047] - The term "SD" refers to standard deviation and is linked to the normal deviation of any validation assay / system.

[0048] - "cartilage damage" as used herein includes damage resulting from injury such as traumatic injury, cartilage disease or arthritis. Examples of cartilage damage that can be treated by administering the compounds described herein include, but are not limited to, arthritis such as osteoarthritis, cartilage injury, fractures affecting articular cartilage or surgical procedures having impact on articular cartilage (e.g., microfractures). Degenerative diseases / disorders of cartilage or joints, such as chondrocalcinosis, polychondritis, relapsing polychondritis, ankylosing spondylitis or costochondritis, are also encompassed by this term. The International Cartilage Repair Society has proposed an arthroscopic grading system to assess the severity of cartilage defects: Grade 0: (normal) healthy cartilage, Grade 1: cartilage has soft spots or blisters, Grade 2: minor tears are seen in the cartilage, Grade 3: the damage has deep gaps (more than 50% of the cartilage layer), and Grade 4: cartilage tears expose the underlying (subchondral) bone (see, for example, page 13 of http: / / www.cartilage.org / _files / contentmanagement / ICRS_evaluation.pdf).

[0049] - The term "osteoarthritis" is used to refer to the most common form of arthritis. The term "osteoarthritis" encompasses both primary and secondary osteoarthritis (see, for example, The Merck Manual, 17th edition, p. 449). The most common way of classifying / grading osteoarthritis is by using the Kellgren-Lawrence radiographic grading scale (see table below). Osteoarthritis can be caused by the destruction of cartilage. Pieces of cartilage can break off, causing pain and swelling in the joints between the bones. Over time, the cartilage can wear away completely, causing the bones to rub together. Osteoarthritis can affect any joint, but usually concerns the hands, and weight-bearing joints such as the hip, knee, foot, and spine. In a preferred example, osteoarthritis can be knee osteoarthritis or hip osteoarthritis. Osteoarthritis is one of the preferred cartilage disorders that can be treated by administering a compound according to the present invention.

[0050] The Kellgren-Lawrence radiographic grading scale for osteoarthritis (KL) is described as follows: [Table 1]

[0051] Grades 1 and 2 can be considered as less severe forms of the disease, while grades 3 and 4 can be considered as more severe forms of the disease.

[0052] - The term "cartilage injury" as used herein refers to cartilage damage or cartilage injury, especially resulting from trauma. Cartilage injury may occur especially after traumatic mechanical destruction, especially associated with accidents or surgery (e.g. microfracture surgery). The term "cartilage injury" also includes cartilage or osteochondral fractures, damage to menisci, and the term microfracture. Sports-related injuries or sports-related wear of articular tissues are also considered to be included in this definition.

[0053] - "WOMAC total score" or "WOMAC score" ("WOMAC" stands for "Western Ontario and McMaster Universities Osteoarthritis Index") represents the degree of pain (WOMAC pain score), function (WOMAC function score) and stiffness (WOMAC stiffness score). When applied to the evaluation of pain and functional impairment associated with cartilage damage, it consists of a questionnaire containing 24 items divided into three subscales (5 items for pain, 2 items for stiffness and 17 items for physical function) (see Bellamy et al., 1988; Wolfe, 1999). It is a well-known and widely used instrument, especially in the evaluation of OA severity.

[0054] - To assess cartilage repair, cartilage volume measurements were performed through magnetic resonance imaging (MRI) measurements, including outer cartilage volume (also referred to as LFTC), inner cartilage volume (also referred to as MFTC), total cartilage volume (also referred to as LFTC+MFTC) and new total mean cartilage thickness.

[0055] - The term "thin" cartilage refers to cartilage with a JSW lower than or equal to 3.5±2SD mm.

[0056] - The term "thick" cartilage refers to cartilage with a JSW higher than 3.5±2SDmm.

[0057] - The term "baseline" means before treatment (i.e., at the time of study enrollment). It particularly refers to clinical variables such as, but not limited to, cartilage volume and WOMAC total score of a given subject at the time of study enrollment (i.e., before treatment with an active compound or placebo).

[0058] - The term "subject" or "patient" refers to both human and non-human animals. The term non-human includes mammals such as rodents (including mice), rabbits, cats, dogs, horses, cows, sheep, or primates.

[0059] - "susceptible subjects" are subjects that exhibit a response to the treatment of cartilage disorders with an active compound. Preferably, sensitive subjects (or subjects that are / may be sensitive / responsive to the treatment) exhibit a particularly higher increase in total cartilage thickness and / or cartilage volume than placebo-treated subjects, i.e., exhibit cartilage repair. Additionally, sensitive subjects exhibit an improvement in WOMAC total score that is at least similar to placebo. The terms "susceptible" (including both "good sensitivity" and "moderate sensitivity") and "non-susceptible" (including "low sensitivity") refer to different groups of subjects, depending in particular on the increase in cartilage volume after treatment with an active compound. Good sensitivity subjects exhibit a high response (i.e. high cartilage repair) to treatment with an active compound, moderate sensitivity subjects exhibit an intermediate response (i.e. intermediate cartilage repair) to treatment with said active compound, and non-susceptible subjects exhibit no or low response to treatment with said active compound. Good sensitivity subjects preferably have an improvement in WOMAC total score that is similar to placebo. Conversely, non-responders have an improvement in WOMAC total score that is significantly less than placebo.

[0060] More specifically, the terms "intermediate sensitives", "good sensitives", "non-sensitives", "intermediate responders", "good responders" and "non-responders" (including poor responders) relate to different groups of subjects depending on the increase in cartilage volume and improvement in WOMAC total score after treatment with an active compound.

[0061] Suggested criteria for assessing susceptibility / response may be selected from one or more of the following (but are not limited to): 1. Positive cartilage gain compared to baseline, 2. A change in cartilage gain that is significantly greater than the change in placebo (e.g., when tested using a linear model with alpha = 5%, adjusting for BMI, KL grade, sex and age), 3. An improvement, i.e., a decrease, in WOMAC score compared to baseline (e.g., a reduction of greater than 5 points); 4. WOMAC score change not significantly higher than the change on placebo (e.g., when adjusted for BMI, KL grade, sex and age and tested using a linear model with alpha=5%).

[0062] - "Response" or "sensitivity" to active compound treatment for cartilage disorders should be understood as measured as 1) an increase in cartilage volume, measured for example using MRI or X-ray, 2) a decrease in WOMAC total score, or 3) a change in WOMAC total score not significantly higher than that from placebo, at least one year or better two years after the first injection (see also the definition of "sensitivity").

[0063] - The term "placebo effect" as used herein should be understood as a change compared to the baseline due to contextual influences (e.g. the procedure of intra-articular injection by the physician) and due to patient expectations, due to the placebo itself (e.g. dilution of inflammatory components in the synovial fluid). The term "low placebo effect" refers to a response magnitude comparable to that at baseline, within the standard deviation of the evaluation method.

[0064] - The term "storage device", as used herein, is intended to include any suitable computing or processing device or other device configured or adapted to store data or information. Examples of electronic devices suitable for use with the present invention include stand-alone computing devices, data telecommunications networks, including local area networks (LANs), wide area networks (WANs), the Internet, intranets, and extranets, as well as local and distributed computer processing systems. Storage devices also include, but are not limited to, magnetic storage media, such as floppy disks, hard disk storage media, magnetic tape, optical storage media, such as CD-ROMs, DVDs, electronic storage media, such as RAM, ROM, EPROM, and EEPROM, general purpose hard disks, and hybrids of these categories, such as magnetic / optical storage media.

[0065] - As used herein, the term "stored" refers to a process for encoding information on a storage device. One of skill in the art can readily employ any currently known method for recording information on a known medium to generate a product that includes expression level information.

[0066] Detailed Description of the Invention Besides 1) predicting placebo response in subjects with cartilage damage, there is a need to 2) predict the clinical effectiveness (particularly with regard to cartilage repair) of active compound treatment for the treatment of subjects with cartilage damage, such as osteoarthritis, cartilage injury, fractures affecting articular cartilage, or surgical procedures with impact on articular cartilage (e.g., microfractures). In order to optimize the management of clinical trials or to optimize the treatment of said subjects, especially with regard to cartilage repair, it is important to identify markers that can be used as predictors of 1) placebo response and / or 2) response of a given subject to active compound treatment. Such predictive biomarkers may be used to 1) identify groups of subjects at risk of showing a placebo effect and / or 2) high-risk groups that are either low or conversely sensitive (e.g., moderate or good sensitivity) or even highly sensitive to the treatment. For example, if a subject with osteoarthritis is known to be at high risk for moderate response (or moderate sensitivity) to the treatment, the physician may decide to adapt a dosing regimen, for example, to administer a higher dose of active compound to said subject and / or to administer the drug for a longer period of time. Such predictive information may be clinically useful to guide medical decisions, particularly regarding the dosing regimen or length of treatment to be applied to a patient, or the timing of joint replacement surgery if necessary (e.g., when active compound treatment is predicted to be less effective).

[0067] The surprising findings of the present invention are based on different studies that aimed to identify potential markers associated with the administration of different active compounds. The biomarkers used in these studies consisted of a number of protein biomarkers. The physical markers were JSW measurements. The association between protein markers and / or physical markers and clinical response variables was evaluated. The rationale for this type of analysis was to identify combinations of markers that could predict 1) placebo response and / or 2) clinical outcome (particularly with regard to cartilage repair) for subjects treated with active compounds such as FGF-18 compounds, BMP-2, BMP-7, GDF-5, FGFβ, FGF-9, SOX-9 enhancers, TGFβ, Wnt inhibitors, anti-MMP13 inhibitors, anti-ADAMTS4 or 5 inhibitors, calcitonin and any variants or fusion proteins thereof. In particular, it was surprisingly found that 1) JSW measurements can be used to predict placebo effect and 2) protein biomarkers can be used together with JSW measurements to stratify and target specific subject populations.

[0068] Different markers have demonstrated changes in response to active compound therapy or have shown changes in outcomes (i.e. cartilage thickness or volume, WOMAC score) by applying criteria for high and low values. Examples are C1M, C3M and hs-CRP. The inventors have surprisingly found associations between certain metabolic proteins in combination with physical markers and outcomes (e.g. cartilage repair). Of particular interest are the proteins CTX-II and ProC2. It is noted that only CTX-II and / or ProC2 are specifically mentioned herein, but other metabolic biomarkers such as PIIANP, C2M, ARGS or AGNx1 may be used. Based on the teachings of the present invention, it is a matter of routine for the skilled artisan to find threshold values ​​for each of these biomarkers. These proteins have been described in the literature as possible related to osteoarthritis. For example, CTX-II and ProC2 may be considered as metabolic biomarkers (Bay-Jensen, 2016).

[0069] Surprisingly, the inventors have found that for a given subject (with cartilage damage) that shows a JSW higher than 3.5±2SDmm, whatever the level of biomarkers, there is a strong placebo effect among these subjects, which may bias the results of clinical trials by hiding the actual lack of effect of a given active compound, and may subsequently bias treatment.Surprisingly, it has also been found that when the amount of metabolic biomarkers such as CTX-II and / or ProC2 is reduced and JSW is lower than a certain limit, this combination is associated with a better response to treatment with active compounds such as FGF-18 compounds, BMP-2, BMP-7, GDF-5, FGFβ, FGF-9, SOX-9 enhancers, TGFβ, Wnt inhibitors, anti-MMP13 inhibitors, anti-ADAMTS4 or 5 inhibitors, calcitonin and any variants or fusion proteins thereof in subjects suffering from cartilage damage.Such subjects are called good sensitivity (or good responders). On the contrary, it has also been surprisingly found by the present inventors that when the amount of CTX-II and / or ProC2 increases and JSW is higher than a certain limit, this is associated with the absence or low response (i.e., low sensitivity or non-sensitivity to treatment with said active compound) in subjects suffering from cartilage damage. Such subjects are called non-responsive (or non-responder). Alternatively, 1) when the amount of metabolic biomarkers such as CTX-II and / or ProC2 decreases and JSW is higher than a certain limit, or 2) when the amount of metabolic biomarkers such as CTX-II and / or ProC2 increases and JSW is lower than a certain limit, this may be associated with intermediate response, i.e., the subject is an intermediate responsive (or intermediate responder).

[0070] It is therefore a discovery of the present invention that metabolic biomarkers such as CTX-II and / or ProC2 in combination with the physical marker JSW can be used as predictive markers of one's subject's responsiveness to active compound treatment such as FGF-18 compounds, BMP-2, BMP-7, GDF-5, FGFβ, FGF-9, SOX-9 enhancers, TGFβ, Wnt inhibitors, anti-MMP13 inhibitors, anti-ADAMTS4 or 5 inhibitors, calcitonin and any variants or fusion proteins thereof. Preferably, the subject has a cartilage disorder such as osteoarthritis, cartilage injury, a fracture affecting articular cartilage or a surgical procedure (e.g., microfracture) having an impact on articular cartilage. In certain embodiments, a subject is predicted to be insensitive to active compound treatment if the amount of CTX-II is higher than 350±2SDng / mmol CTX-II (>240-260% of normal mean) and / or the amount of ProC2 is higher than 4.2±2SDng / mL (>120-280% of normal mean) and JSW is higher than 3.5±2SDmm. Conversely, a subject is predicted to be sensitive to active compound treatment if the amount of CTX-II is lower than 350±2SDng / mmol and / or the amount of ProC2 is lower than 4.2±2SDng / mL and JSW is lower than or equal to 3.5±2SDmm. A subject is predicted to be intermediately sensitive to active compound treatment if 1) the amount of CTX-II is lower than 350±2SDng / mmol and / or the amount of ProC2 is lower than 4.2±2SDng / mL and higher than 3.5±2SDmm JSW, or 2) the amount of CTX-II is higher than 350±2SDng / mmol and / or the amount of ProC2 is higher than 4.2±2SDng / mL and lower than 3.5±2SDmm JSW.

[0071] The present invention therefore relates to a method for reducing risk in a clinical trial or for determining a placebo effect in a clinical trial, said clinical trial relating to the treatment of cartilage disorders in a subject with an active compound, or during treatment with an active compound, comprising: a) measuring joint space width (JSW) in at least one knee of a subject; and b) predicting the risk of placebo effect for said subject from the results of step a) The present invention relates to a method, comprising:

[0072] According to the method, the presence of a JSW higher than 3.5±2 SD mm predicts a placebo effect. Conversely, the presence of a JSW lower than or equal to 3.5±2 SD mm predicts no or low placebo effect. - For clinical trials, clinicians can easily classify subjects depending on their likelihood of showing a placebo effect or not. - For the treatment of cartilage disorders, a physician can readily determine whether a subject is likely to be susceptible (including both intermediate and highly susceptible) to a given active compound treatment.

[0073] Alternatively, the present invention provides a method for reducing risk in a clinical trial or determining a placebo effect in a subject in a clinical trial, said clinical trial relating to the treatment of cartilage disorders in a subject with an active compound, or during treatment with an active compound, comprising: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; b) measuring the joint space width (JSW) in at least one knee of the subject; and c) predicting the risk of placebo effect from the results of steps a) and b) wherein steps a) and b) are performed in any order; The method is targeted.

[0074] Before determining the amount of at least one of the biomarkers, it is necessary to obtain a sample (or biological sample or test sample) from said subject, for example by collection of blood, serum, synovial fluid or urine. Thus, the present invention relates to a method for determining a placebo effect in a subject in a clinical trial (which clinical trial concerns the treatment of a cartilage disorder in a subject with an active compound) or during treatment with an active compound, comprising: a) obtaining a sample from said patient and determining from said sample the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; b) measuring the joint space width (JSW) in at least one knee of the subject; and c) predicting the risk of placebo effect for said subject from the results of steps a) and b) wherein steps a) and b) are performed in any order; The method is targeted.

[0075] According to the method, the presence of a CTX-II higher than 350±2SDng / mmol (>240-260% of the normal mean) and / or a ProC2 higher than 4.2±2SDng / mL (>120-280% of the normal mean) together with a JSW higher than 3.5±2SDmm is predictive of a placebo effect. Similarly, the presence of either 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL together with a JSW higher than 3.5±2SDmm, or 2) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL together with a JSW lower than 3.5±2SDmm is predictive of a placebo effect. Conversely, the presence of a CTX-II lower than 350±2 SD ng / mmol and / or a ProC2 lower than 4.2±2 SD ng / mL together with a JSW lower than or equal to 3.5±2 SD mm predicts no or low placebo effect.

[0076] From the above prediction, - For clinical trials, clinicians can easily classify subjects depending on their likelihood of showing a placebo effect or not. - For the treatment of cartilage disorders, a physician can readily determine whether a subject is likely to be susceptible (including both intermediate and highly susceptible) to a given active compound treatment.

[0077] The present invention also provides a method of reducing risk in a clinical trial, the clinical trial involving the treatment of a cartilage disorder in a subject with an active compound, the method comprising: c) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; d) measuring the joint space width (JSW) in at least one knee of the subject; and e) predicting the response of said subject to treatment with said active compound from the results of steps a) and b). wherein steps a) and b) are performed in any order; The method is targeted.

[0078] Before determining the amount of at least one of the biomarkers, it is necessary to obtain a sample (or biological or test sample) from the subject, for example by collection of blood, serum, synovial fluid or urine. Thus, the present invention relates to a method for reducing risk in a clinical trial, the clinical trial relating to the treatment of a cartilage disorder in a subject with an active compound, the method comprising: a) obtaining a sample from said patient and determining from said sample the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; b) measuring the joint space width (JSW) in at least one knee of the subject; and c) predicting the response of said subject to treatment with said active compound from the results of steps a) and b). wherein steps a) and b) are performed in any order; The method is targeted.

[0079] According to the method, the presence of a CTX-II higher than 350±2SDng / mmol (>240-260% of the normal mean) and / or a ProC2 higher than 4.2±2SDng / mL (>120-280% of the normal mean) together with a JSW higher than 3.5±2SDmm is predictive of no or low response (i.e. no or low sensitivity) to treatment with an active compound. The subject is therefore predicted to be an insensitive (or non-responder). Conversely, the presence of a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL together with a JSW lower than or equal to 3.5±2SDmm is predictive of a good response (i.e. good sensitivity) to treatment with an active compound. The subject is therefore predicted to be a good sensitivity (i.e. good responder) to treatment with said active compound. The presence of either 1) CTX-II lower than 350±2SDng / mmol and / or ProC2 lower than 4.2±2SDng / mL and JSW higher than 3.5±2SDmm, or 2) CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm predicts an intermediate response (i.e., intermediate sensitivity) to treatment with an active compound. The subject is therefore predicted to be intermediately sensitive (i.e., intermediate responder) to treatment with the active compound. From the prediction, the physician can easily select only those subjects predicted to be sensitive to a given active compound treatment, including both intermediate and good sensitivity subjects.

[0080] The present application also relates to a method for selecting a subject having a cartilage disorder for treatment with an active compound or for inclusion in or exclusion from a clinical trial based on the likelihood of susceptibility to said treatment, comprising: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring joint space width (JSW) in at least one knee of said subject, wherein the amount of at least one of these proteins and the width of JSW are predictive for the subject's risk for being sensitive or insensitive to said treatment; and b) selecting intermediately and / or normally susceptible subjects as suitable for said treatment or clinical trial; The present invention encompasses a method comprising the steps of:

[0081] Before determining the amount of at least one of the biomarkers, it is necessary to obtain a sample (or biological or test sample) from said subject, for example by collection of blood, serum, synovial fluid or urine.The present invention therefore relates to a method for selecting subjects with cartilage disorders for treatment with an active compound or for inclusion in or exclusion from a clinical trial, based on their possible sensitivity to said treatment, comprising: a) obtaining a sample from the patient and determining from the sample the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2, and measuring joint space width (JSW) in at least one knee of the subject, wherein the amount of at least one of these proteins and the width of JSW are predictive of the subject's risk for being sensitive or insensitive to the treatment; and b) selecting intermediately and / or normally susceptible subjects as suitable for said treatment or clinical trial; The present invention is directed to a method, comprising:

[0082] According to the method, subjects who show a JSW higher than 3.5±2SDmm with a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL are preferably excluded from treatment with active compounds. Conversely, subjects who show a JSW lower than or equal to 3.5±2SDmm with a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL are preferably included (i.e., the subjects are preferably selected) for treatment with active compounds. Subjects exhibiting either 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm, or 2) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL with a JSW lower than 3.5±2SDmm are also included for treatment with an active compound, optionally with alternative dosing regimens in which the dose of the active compound is increased and / or the active compound is administered for a longer treatment period.

[0083] Alternatively, there is provided a method of treating a subject having a cartilage disorder with an active compound, comprising: a) determining the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 from a sample from the subject and measuring joint space width (JSW) in at least one knee of the subject, said amount and width being predictive regarding the subject's risk for being susceptible to treatment with the active compound; b) Below: i. CTX-II lower than 350±2SDng / mmol, and / or ProC2 lower than 4.2±2SDng / mL and JSW lower than or equal to 3.5±2SDmm; ii. A CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm; or iii. JSW lower than 3.5±2SDmm with CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL selecting a subject having c) administering said active compound to said selected subject. A method is described herein, comprising:

[0084] Before determining the amount of at least one of the biomarkers, it is necessary to obtain a sample (or biological or test sample) from said subject, for example by collection of blood, serum, synovial fluid or urine. Thus, the present invention provides a method of treating a subject with a cartilage disorder with an active compound, comprising: a) obtaining a sample from said patient and determining from said sample the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring the joint space width (JSW) in at least one knee of said subject, said amount and width being predictive with respect to the subject's risk for being sensitive to treatment with said active compound; b) Below: i. CTX-II lower than 350±2SDng / mmol, and / or ProC2 lower than 4.2±2SDng / mL, and JSW lower or equal to 3.5±2SDmm, ii. A CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm; or iii. JSW lower than 3.5±2SDmm with CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL selecting a subject having c) administering said active compound to said selected subject. The present invention relates to a method, comprising:

[0085] Intermediately sensitive subjects (having either: 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm or 2) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL with a JSW lower than 3.5±2SDmm) may be treated with the same dosing regimen as well as well sensitive subjects (having a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL and a JSW lower than or equal to 3.5±2SDmm), but these subjects may have better benefit with alternative dosing regimens.

[0086] Accordingly, there is provided a method of treating a subject with a cartilage disorder with an active compound, comprising: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring joint space width (JSW) in at least one knee of said subject, said amount and width being predictive with respect to the subject's risk for being intermediately sensitive to treatment with said active compound; b) Below: i. CTX-II lower than 350±2SDng / mmol, and / or ProC2 lower than 4.2±2SDng / mL and JSW higher than 3.5±2SDmm, or ii. CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm selecting a subject having c) administering the active compound to the selected subject according to an alternative dosing regimen in which the dose of the active compound is increased and / or the active compound is administered for a longer treatment period compared to a normal dosing regimen for the active compound. Also described herein are methods, including:

[0087] Before determining the amount of at least one of the biomarkers, it is necessary to obtain a sample (or biological or test sample) from said subject, for example by collection of blood, serum, synovial fluid or urine. Thus, the present invention provides a method of treating a subject with a cartilage disorder with an active compound, comprising: a) obtaining a sample from said patient and determining from said sample the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2 and measuring joint space width (JSW) in at least one knee of said subject, said amount and width being predictive with respect to the subject's risk for being intermediately sensitive to treatment with said active compound; b) Below: i. CTX-II lower than 350±2SDng / mmol, and / or ProC2 lower than 4.2±2SDng / mL and JSW higher than 3.5±2SDmm, or ii. CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm selecting a subject having c) administering the active compound to the selected subject according to an alternative dosing regimen in which the dose of the active compound is increased and / or the active compound is administered for a longer treatment period compared to a normal dosing regimen for the active compound. The present invention is directed to a method, comprising:

[0088] The amount (or expression level) of one or more biomarkers in a sample may, if necessary, be compared against a reference amount (alternatively, a reference expression level, baseline amount or baseline expression level) from a reference sample. The reference level may be obtained from a healthy subject or from the very same patient diagnosed or treated before or during said treatment. The joint space width of a subject may, if necessary, be compared against a reference joint space width (or baseline joint space width). The reference width may be obtained from a healthy subject or from the very same patient diagnosed or treated before or during said treatment.

[0089] The present invention further includes an active compound for use in treating subjects with cartilage disorders, characterized in that the subjects have either: 1) CTX-II lower than 350ng / mmol and / or ProC2 lower than 4.2ng / mL and JSW lower than or equal to 3.5±2SDmm, 2) CTX-II lower than 350ng / mmol and / or ProC2 lower than 4.2ng / mL and JSW higher than 3.5±2SDmm, or 3) CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm. Intermediately sensitive subjects can be treated with the same dosing regimen as well as well sensitive subjects, but these subjects may benefit better with alternative dosing regimens.

[0090] Therefore, the present invention also encompasses an active compound for use with an alternative dosing regimen (e.g., increased dose of active compound and / or longer treatment duration) in the treatment of a subject with cartilage damage, characterized in that the subject has either 1) CTX-II lower than 350ng / mmol and / or ProC2 lower than 4.2ng / mL and JSW higher than 3.5±2SDmm, or 2) CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm. Accordingly, subjects who do not meet these criteria are preferably excluded from the active compound treatment.

[0091] The present invention also relates to an assay for determining sensitivity to active compound treatment or for determining a treatment regimen with a given active compound, comprising: (a) subjecting a test sample from a human subject diagnosed with cartilage damage to at least one assay for determining the amount of at least one of CTX-II and / or ProC2; (b) determining the amount of at least one of CTX-II and / or ProC2; and (c) determining the sensitivity or non-sensitivity of the subject to treatment with the active compound from the results of step b) taking into account joint space width measurements. According to the assay, the presence of CTX-II higher than 350ng / mmol and / or ProC2 higher than 4.2ng / mL with JSW higher than or equal to 3.5±2SDmm predicts non-sensitivity to treatment with the active compound. Conversely, the presence of CTX-II lower than 350ng / mmol and / or ProC2 lower than 4.2ng / mL with JSW lower than or equal to 3.5±2SDmm predicts good sensitivity. Alternatively, the presence of either 1) CTX-II lower than 350ng / mmol and / or ProC2 lower than 4.2ng / mL with JSW higher than 3.5±2SDmm, or 2) CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL with JSW lower than 3.5±2SDmm predicts intermediate sensitivity. From the results of the assay, a physician can easily select only those subjects who are predicted to be sensitive to active compound treatment, including both intermediate and good sensitive subjects. In the above disclosed assay, before determining the amount of at least one biomarker, it is necessary to obtain a biomarker (or test) sample from the subject, for example, by collecting blood, serum, synovial fluid or urine.

[0092] The present invention is also directed to an assay for selecting a treatment regimen for a human subject having a cartilage disorder, comprising: (a) subjecting a test sample from a human subject diagnosed with a cartilage disorder to at least one assay for determining the amount of at least one of CTX-II and / or ProC2; (b) determining from step a) the likelihood that the subject will be moderately or well-sensitive to active compound treatment, taking into account the joint space width measurements; and (c) determining an appropriate treatment regimen for the subject from the results of step b). When the assay is performed, the subject is assayed for CTX-II lower than 350 ng / mmol and / or ProC2 lower than 4.2 ng / mL with a JSW lower than or equal to 3.5±2SDmm, based on the recognition that the following amounts / ranges are associated with a good response to the compound, or for CTX-II lower than 350 ng / mmol and / or ProC2 lower than 4.2 ng / mL with a JSW higher than 3.5±2SDmm, based on the recognition that the following amounts / ranges are associated with a moderate response to the compound, if the subject has 1) CTX-II lower than 350 ng / mmol and / or ProC2 lower than 4.2 ng / mL with a JSW higher than 3.5±2SDmm, or 2) CTX-II lower than 350 ng / mmol and / or ProC2 lower than 4.2 ng / mL with a JSW higher than 3.5±2SDmm, based on the recognition that the following amounts / ranges are associated with a moderate response to the compound, If a subject has a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL and a JSW lower than 3.5±2SDmm, the subject may be selected for and treated with an appropriate dosage regimen containing an effective amount of the active compound, and based on the recognition that the following amounts are associated with an inadequate response to treatment with the compound, if the subject has a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL with a JSW higher than 3.5±2SDmm, the subject may be excluded from treatment with the active compound. Intermediately sensitive subjects may be treated with the same dosage regimen as well sensitive subjects, but these subjects may have better benefits with alternative dosage regimens. Therefore, alternatively, the intermediately sensitive subjects may be selected for and treated with an alternative dosage regimen (e.g., an increased dose of the active compound and / or a longer treatment period) with the active compound.

[0093] Further disclosed is a method of treating a human subject having a cartilage disorder, comprising the steps of: (a) assaying a biological sample from a subject diagnosed with a cartilage disorder for the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; (b) measuring joint space width; and (c) administering to the subject a treatment regimen comprising a composition comprising an effective amount of an active compound if the subject has 1) a CTX-II lower than 350±2SDng / mmol and / or a ProC2 lower than 4.2±2SDng / mL and a JSW lower than or equal to 3.5±2SDmm, 2) a CTX-II lower than 350ng / mmol and / or a ProC2 lower than 4.2ng / mL with a JSW higher than 3.5±2SDmm, or 3) a CTX-II higher than 350±2SDng / mmol and / or a ProC2 higher than 4.2±2SDng / mL and a JSW lower than 3.5±2SDmm. Although moderately sensitive subjects can be treated with the same dosing regimen as well sensitive subjects, these subjects will benefit better with alternative dosing regimens.Therefore, alternatively disclosed is a method for treating a human subject with cartilage damage, comprising: (a) assaying a biological sample of a subject diagnosed with cartilage damage for the amount of at least one biomarker selected from the group consisting of CTX-II and / or ProC2; (b) measuring joint space width; and (c) administering to the subject an alternative treatment regimen (e.g., an increased dose and / or longer treatment period of the active compound) comprising a composition when the subject 1) has CTX-II lower than 350±2SDng / mmol and / or ProC2 lower than 4.2±2SDng / mL and JSW higher than 3.5±2SDmm, or 2) has CTX-II higher than 350±2SDng / mmol and / or ProC2 higher than 4.2±2SDng / mL and JSW lower than 3.5±2SDmm.

[0094] In the context of the present invention as a whole, CTX-II and / or ProC2 have been shown to be useful predictive biomarkers of the placebo response and response of subjects to active compounds for treating cartilage disorders.Therefore, they are considered predictive biomarkers.Other metabolic biomarkers such as C2M, ARGS or AGNx1 can be used instead.

[0095] In the context of the present invention as a whole, preferred cartilage disorders are selected from the group consisting of osteoarthritis, cartilage injuries, fractures affecting articular cartilage or surgical procedures having an impact on articular cartilage, such as microfractures.

[0096] In the context of the invention as a whole, for example in the context of any one of the methods, uses, assays or kits according to the invention, preferred active compounds may be selected from FGF-18 compounds (including truncated FGF-18 compounds such as sprifermin), BMP-2, BMP-7, GDF-5, FGFβ, FGF-9, SOX-9 enhancers, TGFβ, Wnt inhibitors, anti-MMP13 inhibitors, anti-ADAMTS4 or 5 inhibitors, calcitonin and any variant or fusion protein thereof.

[0097] As an example of a dosing schedule, when the active compound according to the present invention as a whole is an FGF-18 compound, said FGF-18 compound is usually administered intra-articularly to a subject (preferably a well-sensitive subject) at a dose of 100mcg per injection once per week for three weeks per treatment cycle. A proposed dosing regimen for those subjects who are expected to be hyper-sensitive is intra-articular administration of FGF-18 compound at a dose of 30mcg per injection once per week for three weeks per treatment cycle. The preferred dose then is 100mcg per injection, but it should be understood that it is optionally reduced to 30mcg per injection for hyper-sensitive subjects, and the present invention is not limited to said dosage. Thus, the FGF-18 compound can be administered intra-articularly at a dose comprised between 50 and 300mcg per injection, preferably between 60 and 250mcg, or even more preferably between 100 and 200mcg. For ultrasensitive subjects, the dose may be reduced, for example, by 1 / 2 or about 1 / 2 or by 1 / 3 or about 1 / 3. For example, if the normal dose is 50 mcg per injection, the reduced dose may be comprised between 16 and 25 mcg per injection. The FGF-18 compound is usually administered for at least one cycle of treatment. Preferably, the cycle is repeated at least once, for example, 6 months (or about 26 weeks) after the start of the first treatment cycle. Up to four treatment cycles within two years have shown promising results (see FIG. 1). Obviously, if the subject is predicted to be intermediately sensitive to the active compound, an alternative dosing regimen may consist of additional treatment cycles.

[0098] As another example of a dosing schedule, if the active compound according to the invention as a whole is a calcitonin compound, said calcitonin compound is usually administered orally at a dose of 0.8 mg twice a day for 24 months or longer if necessary, or any typical dosing regimen is administered for said compound. If necessary, the oral dose and length of treatment can be adapted to the subject's response or likelihood of response to said treatment for intermediate responders benefiting from said calcitonin treatment.

[0099] In yet another example of a dosing schedule, where the active compound according to the invention as a whole is a BMP-7 compound, said BMP-7 compound is typically administered intra-articularly at a dose of about 0.03mcg / ml to 0.3mcg / ml, such as 0.3, 0.1 or 0.3mcg / ml per injection, optionally repeated, or any typical dosing regimen administered for said compound. If necessary, the oral dose and length of treatment can be adapted to the subject's response or likelihood of response to said treatment.

[0100] In the context of the invention as a whole, assaying or other determination of the amount of at least one of the biomarkers of the invention can be performed before or during treatment. Indeed, even during treatment, the dosing regimen may need to be adapted to new marker status.

[0101] In the context of the present invention as a whole, for patients with a CTX-II in the range of 350±2SDng / mmol or ProC2 in the range of 4.2±2SDng / mL, it is prudent to complete a diagnostic or biomarker test using another metabolic biomarker. For example, if the CTX-II level is in the range of 350±2SDng / mmol, the ProC2 level may be considered. In the rare case where a patient shows a range of 350±2SDng / mmol CTX-II and 4.2±2SDng / mL ProC2, it is prudent to complete a diagnostic or biomarker test using another type of biomarker, such as an inflammatory biomarker or SNP biomarker, such as those disclosed in WO2014023703.

[0102] In the context of the present invention as a whole, the joint space width is preferably determined by X-ray or MRI techniques. Obviously, the skilled person can use alternative techniques where preferred.

[0103] In another embodiment of the present invention, a system for obtaining data (and a computer readable medium for causing the computer system therefor) is also provided. The data can be used in particular to evaluate the suitability for clinical trials or the suitability of treatment with an active compound in a subject, or to monitor the therapeutic effectiveness of an active compound for a given subject, or simply to monitor disease progression. The system can be used during clinical trials when treatment with an active compound is to be envisaged for treating cartilage disorders, or when treatment with the compound is already in progress.

[0104] Thus, one embodiment of the present invention includes a computer system for obtaining data regarding JSW for at least one subject having a cartilage disorder together with data from at least one test sample obtained from said subject, the computer system comprising: (a) at least one determination module configured to receive data regarding JSW from a patient together with at least one test sample from said subject and to perform at least one analysis on said at least one test sample to determine an amount of at least one biomarker according to the present invention; (b) at least one storage device configured to store data output from said determination module; and (c) at least one display module for displaying content based in part on data output from said determination module, the content comprising a signal indicative of the presence of at least one of these conditions, and optionally the absence of any one of these conditions.

[0105] A computer readable medium can have computer readable instructions recorded thereon to define a software module for executing a method on a computer. In such a case, the computer readable storage medium may include (a) instructions for comparing data stored on a storage device with reference data to provide a comparative result, the comparison being based on the amount of at least one of the biomarkers according to the invention and joint space width, and (b) instructions for displaying content based in part on data output from the determination module, the content including a signal indicative of at least one presence of a condition, and optionally the absence of one or more of the conditions.

[0106] Computer readable storage media can be any available tangible media that can be accessed by a computer. Computer readable storage media includes volatile and non-volatile, removable and non-removable tangible media implemented in any method or technology for storage of information, such as computer readable instructions, data structures, program modules, or other data. Computer readable storage media includes, but is not limited to, random access memory (RAM), read only memory (ROM), erasable programmable read only memory (EPROM), electrically erasable programmable read only memory (EEPROM), flash memory or other memory technology, compact disc read only memory (CD-ROM), digital versatile disk (DVD) or other optical storage media, magnetic cassettes, magnetic tape, magnetic disk storage or other magnetic storage media, other types of volatile and non-volatile memory, and any other tangible media that can be used to store the desired information and that can be accessed by a computer, as well as any suitable combination of the above.

[0107] Computer readable data embodied on one or more computer readable media may define instructions, for example as portions of one or more programs that, when executed by a computer, instruct a computer to perform one or more of the functions described herein and / or various embodiments, variations and combinations thereof. Such instructions may be written in any of a number of programming languages, such as Java, J#, Visual Basic, C, C#, C++, Fortran, Pascal, Eiffel, Basic, COBOL assembly language, and the like, or any of various combinations thereof. The computer readable media on which such instructions are embodied may be located on one or more of any of the components of the system, or the computer readable storage media described herein may be distributed across one or more of such components.

[0108] The computer readable medium may be portable such that the instructions stored thereon may be loaded into any computer resource to carry out the aspects of the invention discussed herein.

[0109] The information determined in the determination module can be read by a storage device adapted or configured to have expression level or protein level information recorded thereon. Such information may be provided in a digital form that can be transmitted and read electronically, for example, via the Internet, on a diskette, via a universal serial bus (USB) or via any other suitable communication mode.

[0110] It should be understood that in the context of the invention as a whole, e.g. any one of the methods, uses, assays, computer systems or kits according to the invention, before determining the amount of at least one of the biomarkers of the invention (e.g. CTX-II and / or ProC2), it is necessary to obtain one subject's sample (or biological sample or test sample), e.g. by collection of blood, serum, synovial fluid or urine. It may also be obtained, without any limitation, from cells, tissues, cartilage or synovial fluid.

[0111] An individual suffering from a cartilage disorder and being tested and / or treated according to any of the methods, uses, assays, kits and other computer systems described herein is a human subject who is a candidate for treatment with an active compound to treat said cartilage disorder. In a preferred embodiment, the individual has been diagnosed as having a cartilage disorder or exhibits symptoms of a cartilage disorder.

[0112] In a further embodiment, the invention encompasses a kit comprising means for carrying out the above method and instructions for use. Preferably, the kit comprises means for detecting the presence of at least one of the biomarkers according to the invention (e.g., CTX-II and / or ProC2) and for quantifying them. The kit may comprise means for detecting the presence of at least two of the biomarkers according to the invention and for quantifying them. The results obtained from the kit need to be combined with the results of the measurement of JSW before any conclusions can be reached.

[0113] The methods and kits according to the invention are useful in clinical diagnostic applications. However, as used herein, the term "diagnosis" is not limited to clinical or medical applications, and the diagnostic methods and kits of the claimed invention of this application are also useful in any research application and during clinical trials where it is desirable to test subjects for the presence or absence of any of the markers described herein.

[0114] In the context of the present invention, the presence of at least one of the biomarkers according to the invention (e.g., CTX-II and / or ProC2) as well as their quantification may be detected by any technique known per se to the person skilled in the art, including ELISA.

[0115] Other embodiments of the invention within the scope of the claims of this application will be apparent to those skilled in the art from consideration of this specification or practice of the invention as disclosed herein. It is intended that the specification, together with the examples, be considered as exemplary only, with the scope and spirit of the invention being indicated by the claims which follow the examples.

[0116] Array description: SEQ ID NO: 1: Amino acid sequence of the biomarker CTX-II. SEQ ID NO:2: Amino acid sequence of the biomarker PROC2. SEQ ID NO: 3: Amino acid sequence of native human FGF-18. SEQ ID NO: 4: Amino acid sequence of recombinant truncated FGF-18 (trFGF-18). SEQ ID NO: 5: Amino acid sequence of salmon calcitonin. SEQ ID NO: 6: Amino acid sequence of human BMP-2 SEQ ID NO: 7: Amino acid sequence of human BMP-7 SEQ ID NO: 8: Amino acid sequence of human GDF-5. SEQ ID NO: 9: Amino acid sequence of human FGFβ. SEQ ID NO: 10: Amino acid sequence of human FGF-9. EXAMPLES

[0117] statistical methods Treatment effects on the primary endpoint were assessed across the dose range using repeated measures analysis of variance (ANOVA, using PROC MIXED in SAS) on absolute change from baseline, including baseline value, treatment group, time, and country as factors and treatment-by-time point as an interaction. The primary efficacy analysis consisted of testing for linear dose relationships and overall treatment effects at 2 years. The significance level was set at 5% two-sided for both studies. Pairwise comparisons (sprifermin vs. placebo, and between sprifermin dose and regimen groups) were performed within the context of this modeling framework. For each pairwise comparison, the difference between treatments and the corresponding 95% confidence intervals (CIs) and p-values ​​are presented. The same ANOVA model used for the primary endpoint was used to assess treatment effects on continuous secondary endpoints such as MRI endpoints, WOMAC endpoints (total, pain, function, and stiffness scores), and radiographic endpoints at each time point and over time. Logistic regression was used to assess treatment effects on binary efficacy endpoints such as OMERACT-OARSI responder rates. Point estimates for each pairwise comparison and corresponding 95% CI and p-values ​​are provided.

[0118] Pain and Functional Assessment WOMAC is a validated instrument used to assess symptom modification in clinical OA studies. This clinical score was developed in 1981 and is regarded as a valid instrument by both clinical researchers and regulatory authorities. WOMAC has been widely used and extensively validated in clinical studies in hip and knee OA.

[0119] Subjects were required to self-answer all 24 questions (i.e., 5 for pain, 2 for stiffness, and 17 for physical function assessment) using either an 11-box NRS rating (with categories of 0-10) for the past 48 hours, e.g., 1, or a 100 mm VAS (visual analog scale; each question is given a score of 0-100) for the past 24 hours, e.g., 2. Different forms of the questionnaire existed for the right and left knees, and to reduce confounding of WOMAC responses by symptoms in the contralateral knee, subjects used the WOMAC questionnaire specific to the target knee.

[0120] For administration of the questionnaires, the instructions for the WOMAC 3.1 Index were followed for both Examples 1 and 2.

[0121] Another instrument for the assessment of pain and function is the KOOS (Knee Injury and Osteoarthritis Outcome Score; Collins et al., 2016 ).

[0122] X-ray evaluation of JSW Changes in JSW measured by X-ray are a recognized endpoint approved by the European Medicines Agency and the US Food and Drug Administration for use in efficacy studies in OA. JSW was measured using standardized techniques. X-rays were also used to assess KL grades in Example 2.

[0123] qMRI assessment The primary endpoint of the DBPC treatment phase was the change from baseline in cartilage thickness in the total femoro-tibial joint as assessed by qMRI at 2 years in the mITT. Total femoro-tibial joint cartilage thickness was calculated in two ways: 1. Average cartilage thickness (total volume divided by total surface area), 2. Total cartilage thickness (sum of cartilage thickness in the medial and lateral compartments).

[0124] Treatment effects on the primary endpoint were assessed across the dose range using a repeated measures analysis of variance (ANOVA) on absolute change from baseline with treatment group, time point, and country (pooled) as fixed factors and baseline value as a covariate and treatment by time point as an interaction. Repeated measures over time were accounted for using an "unstructured" covariance pattern.

[0125] Pairwise comparisons of absolute change from baseline in cartilage thickness (compound treatment group vs. placebo) were performed within the context of the modeling framework described above. For each pairwise comparison, the difference between treatments and the corresponding 95% confidence interval (CI) and p-value are presented. p-values ​​(corresponding to fixed-effect type 3 tests) are reported for all covariates in the original "overall" model for all time points combined (i.e. baseline value, treatment, time point, interaction of treatment by time point, country) and for all time points. Estimated coefficients, p-values, and 95% CIs are presented for (i) dose relationships (linear trends) and (ii) each pairwise comparison between dose levels and placebo overall and at each time point.

[0126] To assess the robustness of the primary results, tests for linear dose relationships and overall treatment effects were repeated using the PP Analysis Set. For the mITT Analysis Set, nonparametric analysis was performed on ordered data of cartilage thickness in all femoro-tibial joints as an alternative method for the primary analysis. Data were ordered by the magnitude of absolute change from baseline over 2 years during the DBPC treatment phase using a rank transformation.

[0127] Biomarker measurements Serological and urinary biochemical markers of synovial inflammation as well as bone and joint tissue turnover were evaluated. Potential biomarkers of cartilage metabolism included, but were not limited to, the neoepitope of collagen type II propeptide (proC2) and C-telopeptide cross-linking of type II collagen (CTX-II). Blood and urine samples for systemic biomarker evaluation were collected at the following time points: week 0 (before the first injection of sprifermin), week 26, week 54, week 80, and week 104. For time points where an injection was also administered, samples were collected before the injection. Synovial fluid samples were collected at these time points. These samples were taken immediately before the injection as part of the i.art. injection procedure using the same needle used for the injection. For urine collection, a second morning void was obtained.

[0128] The following assessments were performed as exploratory endpoints: - Changes from baseline in serum and urinary biomarkers associated with administration of the compound. - Baseline protein markers associated with response to treatment or disease progression (response assessed by MRI and / or questionnaire).

[0129] Example 1. Placebo Response and Clinical Efficacy in Subjects Treated with FGF-18 Compounds The FGF-18 compound used as treatment in this example is Sprifermin (defined in the "Definitions" section). Two strengths of Sprifermin were supplied for the study: 30 μg and 100 μg. Sprifermin was supplied as a white, sterile, freeze-dried powder in 3 mL glass vials. Each vial contained either 31.5 μg or 105 μg of Sprifermin active agent, with a 5% excess, which allowed for the extraction of 30 μg or 100 μg of Sprifermin active agent, respectively, after reconstitution with 0.9% w / v sodium chloride injection (referred to herein as "saline solution"). The formulation excipients were sodium phosphate buffer (pH 7.2), sodium hydroxide, O-phosphate, sucrose, and poloxamer 188. The volume administered for all treatment groups was 2 mL.

[0130] The study was based on a prospective study (see study EMR700692-006) in which five groups of patients were studied: Group 1 (4 cycles of placebo; hereafter referred to as placebo or PBO): 108 subjects. Group 2 (2 cycles of sprifermin 30 μg / injection alternating with 2 cycles of placebo; hereafter referred to as sprifermin / placebo 30 μg): 110 subjects. Group 3 (4 cycles of Sprifermin 30 μg / injection; hereafter referred to as Sprifermin 30 μg): 111 subjects. Group 4 (2 cycles of sprifermin 100 μg / injection alternating with 2 cycles of placebo; hereafter referred to as sprifermin / placebo 100 μg): 110 subjects. Group 5 (4 cycles of Sprifermin 100 μg / injection; hereafter referred to as Sprifermin 100 μg): 110 subjects.

[0131] According to a prospective study, patients received four cycles of treatment (each consisting of three weekly intra-articular injections over three consecutive weeks) spaced six months apart (see Figure 1). All injections were intra-articular (given into the joint).

[0132] The primary efficacy endpoint was change from baseline in cartilage thickness in all femoro-tibial joints as assessed by MRI at 2 years. Exploratory endpoints included baseline protein markers associated with response to treatment or disease progression (response assessed by MRI and / or questionnaires).

[0133] Adult subjects of either gender with primary femoro-tibial OA according to the American College of Rheumatology (ACR) clinical and radiographic criteria, with a Kellgren-Lawrence grade (KLG) of 2 or 3 and a minimum joint space width (JSW) of ≥ 2.5 mm in the medial compartment, were enrolled in the study. Subjects must have had pain in the target knee on most days and / or required symptomatic treatment of knee pain with paracetamol (acetaminophen), systemic nonsteroidal anti-inflammatory drugs (NSAIDs) including COX inhibitors (COXibs), or tramadol on most days in the previous month, and had both 1) a history of pain due to OA in the target knee for at least 6 months, and 2) a pain score for the target knee of 4-9 points in response to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Index question 1 ("How much pain did you have when walking on a flat surface [in the target knee over the past 48 hours]?") at screening and baseline after at least 5 half-lives of washout of analgesics: acetaminophen, topical or oral systemic NSAIDs, COXibs, opioids, and / or tramadol. Women of childbearing potential must have used a form of contraception with a failure rate of less than 1% per year throughout the study.

[0134] The main exclusion criteria included >5 degrees malalignment in the femoro-tibial axis of the target knee, clinical signs of inflammation in the target knee (i.e., flushing), i.art. administration of corticosteroids or hyaluronic acid to either knee within 6 months prior to screening, any plans for knee surgery (affecting either the target knee or the contralateral knee) within the next 2 years, concomitant conditions or procedures deemed incompatible with study participation, contraindications to MRI scanning (including inability to fit into the scanner or knee coil), pregnancy or breastfeeding, participation in another clinical study within the past 30 days, and legal incapacity or limited legal capacity.

[0135] Written informed consent had to be obtained prior to any study-related activity.

[0136] Placebo effect based on JSW alone: ​​As shown in Figure 3 (both A and B), the placebo effect in KL2 patients (with JSW>3.5mm) vs. KL3 patients (with JSW≦3.5mm) is very significant. Obviously, it plays a key role in the total WOMAC score, and a simple injection of placebo (PBO) (i.e., salt) is enough to dramatically reduce the WOMAC score for a very long time in KL2 patients, while the WOMAC score increases continuously in KL3 patients despite the injection.

[0137] Placebo effect based on CTX-II or ProC2 levels: Figure 4 highlights that patients with high metabolic biomarker levels, such as CTX-II higher than 350 ng / mmol (Figure 4A) or ProC2 higher than 4.2 ng / mL (Figure 4B), show a higher placebo effect to placebo injections.

[0138] Placebo effect based on combination of JSW+CTX-II levels: As shown in Figure 5, different distributions of CTX-II levels at baseline affect outcome measures such as MRI and WOMAC. Considering the results, thin cartilage (JSW ≦ 3.5 mm) and low levels of metabolic biomarkers (e.g. CTX-II lower or equal to 350 ng / mmol) seem to be the right study population for clinical trials to mitigate the elevated placebo response.

[0139] After treatment with FGF18: As can be seen from Figures 6A and 6B, taking into account the placebo effect, the shape of the response in terms of total WOMAC score changes dramatically for both KL2 and KL3 patients treated with various doses of Sprifermin. The same is true when taking into account CTX-2 levels.

[0140] As is evident from Figures 6C and 6D, when taking into account the placebo effect, the shape of the response in terms of cartilage thickness also changes profoundly for both KL2 and KL3 patients treated with various doses of sprifermin. The same is true when taking into account CTX-2 levels.

[0141] From this example it is clear that stratification can reduce the risk of a clinical trial that would otherwise be biased by the placebo effect in some subgroups of patients.

[0142] Example 2. Placebo Responses in Placebo-Treated Subjects from a Study with Compound X The study was a double-blind, randomized, placebo-controlled, and multicenter clinical trial for the evaluation of Compound X. Approximately 600 patients were enrolled in the placebo arm of the study. Patients were recruited, aged 50-80 years, with painful OA of at least one knee, but otherwise in good general health. The oral drug Compound X and placebo were provided in identical packaging. To be included, patients were required to meet the ACR criteria for the diagnosis of OA. Both knees were evaluated during the study, but a target knee was identified prior to randomization for the evaluation of the primary efficacy endpoint. The target knee had to have been painful for most days of the previous month. Additionally, patients had to meet at least one of the following criteria: age greater than 50 years, experience of morning stiffness lasting less than 30 minutes, or knee crepitus. The target knee had to have a JSW ≥ 2.0 mm at the medial tibiofemoral joint as measured by radiography, and a KL score of 2 or 3. On WOMAC, patients had a score of ≥ 150 mm for pain and / or ≥ 510 mm for function. If both knees met the criteria, the target knee was defined as the knee that met a KL score of 2. If both knees had a KL score of 2, the knee with the highest pain VAS (as long as it was below 80 mm) was selected.

[0143] Exclusion criteria included diseases (other than OA) and medications affecting bone or cartilage metabolism. Pain-relieving medications were permitted as long as they were taken at least 30 minutes after the study drug. Intra-articular injections of corticosteroids or hyaluronic acid in the target knee were prohibited during the study and for 3 months prior to randomization.

[0144] Randomization was stratified by center to ensure that treatment allocation was unbiased and concealed from patients and study staff. The study was performed in accordance with the Declaration of Helsinki. The protocol was approved by an independent ethical committee or institutional review board (IEC / IRB). All subjects or their legal representatives gave informed consent to participate.

[0145] Placebo effect based on the combination of KL+CTX-II levels: As shown in Figure 7, the different distribution of CTX-II levels in KL2 and KL3 subgroups at baseline affects outcome measures such as WOMAC pain. Considering the results, thin cartilage (JSW ≦ 3.5 mm) and low levels of metabolic biomarkers (e.g. CTX-II lower or equal to 350 ng / mmol) seem to be the right study population for clinical trials to mitigate the elevated placebo response.

[0146] Overall conclusion The examples clearly highlight that the KL3 enriched and CTX-II balanced design allows the detection of symptomatic benefits at least until the third year (see FIG. 8). Thus, thin cartilage (lower or equal to 3.5±2SDmm) and low CTX-II (lower or equal to 350±2SDng / mmol) seem to be the best study population for clinical trials to mitigate the elevation of placebo response. Of note, it is trivially possible to use the data of all willing participants, i.e., no patient loss, and it is simply a matter of stratification, patient management. Similarly, based on the results of the examples section, ProC2 levels can be used instead of CTX-II levels. In such a case, thin cartilage and low ProC2 (lower or equal to 4.2±2SDng / ml) are equally suitable study populations for clinical trials to mitigate the elevation of placebo response.

[0147] These findings, demonstrated on two very different clinical trials with two very different active compounds administered via different routes (one injected intra-articularly and the other orally), and this proposed stratification, may reduce the risk of clinical trials for any drug targeting OA due to the possibility of reducing placebo responses, avoiding imbalances between treatment groups, and selecting the right patient population with structural and symptomatic benefits.

[0148] References 1) WO2008 / 023063 2) WO2004 / 032849 3) WO2014 / 023703 4) http: / / www.cartilage.org / _files / contentmanagement / ICRS_evaluation.pdf 5) Lotz, 2010, Arthritis research therapy, 12:211 6) Ellsworth et al., 2002, Osteoarthritis and Cartilage, 10: 308-320 7) Shimoaka et al., 2002, J. Bio. Chem. 277(9):7493-7500 8) Gigout et al., 2017, Osteoarthritis and Cartilage, published online the 18.08.2018 (https: / / doi.org / 10.1016 / j.joca.2017.08.004) 9) Lohmander et al., 2014, Arthritis Rheumatol., Jul;66(7):1820-31 10) Dahlberg et al., 2016, Clin Exp Rheumatol., May-Jun;34(3):445-50 11) Deng et al. 2018, Osteoarthritis and Cartilage, in press: 1-9 12) Parrish et al., 2017, Osteoarthritis Cartilage., Apr;25(4):554-560 13) Ameye and Young 2006. Curr Opin Rheumatol 18:537-547. 14) Zhou et al., 2016, Osteoarthritis Cartilage., Dec;24(12):2181-2192 15) Wang et al. 2014. Birth defects Res C embryo today 102: 37-51 16) Karsdal et al., 2016, Osteoarthritis and Cartilage, 24(12): 2013-2021 17) Duclos et al.,2010, Osteoarthritis Cartilage. 2010 Nov;18(11):1467-76. 18) Gudmann et al., 2016, Arthritis Res Ther., 18(1):141. 19) Munk et al., 2016, Rheumatol Int. 36(4):541-9. 20) Gudmann et al., 2014, Int J Mol Sci. ,15(10):18789-18803. 21) Valdes et al., 2014, Osteoarthritis Cartilage., May;22(5):683-9 22) Struglics et al., 2011, Osteoarthritis Cartilage., Aug;19(8):1047-57 23) Struglics et al., 2015, Arthritis Rheumatol., Jul;67(7):1816-25 24) The Merck Manual, 17 th edition, page 449 25) Bellamy et al., 1988, J. Rheumatology, 15:1833-1840 26) Wolfe, 1999, Rheumatology, 38:355-361 27) Bay-Jensen et al., 2016, Osteoarthritis Cartilage. 24(1):9-20 28) Collins et al. 2016. Osteoarthritis Cartilage 24: 1317 Abbreviation BMI = body mass index; CI = confidence interval; DBPC = double-blind placebo-controlled CTX-II = C-telopeptide cross-linking of type II collagen DBPC = Double-Blind Placebo Controlled ICOAP = Measure of Intermittent and Constant Osteoarthritis Pain ITT=intention-to-treat; JSW=Joint Space Width KOOS Symptom Index = Knee Injury and Osteoarthritis Outcome Score Symptom Index Subscale KOOS QOL = Knee Injury and Osteoarthritis Outcome Score quality of life subscale LOCF = last observation carried forward LFTC=lateral femoro-tibial compartment MFTC=medial femoro-tibial compartment mITT = modified intention-to-treat MOS SF-36=Medical Outcomes Study Short Form-36 General Health Survey MRI = magnetic resonance imaging NRS pain score = numerical rating scale pain score OA = Osteoarthritis PGA = Patient's Global Assessment PGIC = Patient's Global Impression of Change PROC2 = neo-epitope of collagen type-II propeptide WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; W = Week

Claims

1. 1. Use of an FGF-18 compound in the manufacture of a medicament for treating a subject having a cartilage disorder, comprising: the sensitivity of the subject to the FGF-18 compound is determined by detecting the amount of one or both of CTX-II (a C-terminal telopeptide of collagen type II) and ProC2 (a neoepitope of collagen type II) in a biological sample from the subject, and measuring joint space width (JSW) in at least one knee of the subject; If a biological sample from the subject contains CTX-II lower than 350±2 SD ng / mmol, and / or ProC2 lower than 4.2±2 SD ng / mL and JSW equal to or lower than 3.5±2 SD mm, the subject has a good susceptibility to treatment; or the subject has an intermediate sensitivity to treatment if a biological sample from the subject contains (i) a CTX-II lower than 350±2 SD ng / mmol and / or a ProC2 lower than 4.2±2 SD ng / mL and a JSW higher than 3.5±2 SD mm, or (ii) a CTX-II higher than 350±2 SD ng / mmol and / or a ProC2 higher than 4.2±2 SD ng / mL and a JSW lower than 3.5±2 SD mm; The subject having good sensitivity is administered FGF-18 compound intra-articularly at a dose of 30-100 μg per administration, and the subject having moderate sensitivity is administered FGF-18 compound intra-articularly at a dose of about 100 μg per administration.

2. 2. The use according to claim 1, wherein the cartilage disorder is selected from the group consisting of osteoarthritis, cartilage injury, fractures affecting articular cartilage or surgical procedures affecting articular cartilage, and microfractures.

3. The use according to claim 1, wherein said FGF-18 compound comprises amino acid residues 28-196 of SEQ ID NO:1, optionally fused to a heterologous protein or chemical compound.

4. The use according to claim 1, wherein said FGF-18 compound is sprifermin or sprifermin fused to a heterologous protein or chemical compound.

5. 2. The method of claim 1, wherein the FGF-18 compound is administered once a week for a three week treatment cycle.

6. The use according to claim 5, wherein the treatment cycle is repeated.

7. 1. Use of an FGF-18 compound in the manufacture of a medicament for treating a subject having a cartilage disorder, wherein administering the medicament comprises: a) determining the amount of at least one biomarker selected from the group consisting of CTX-II (C-terminal telopeptide of collagen type II) and ProC2 (neoepitope of collagen type II) from a sample from the subject, and measuring joint space width (JSW) in at least one knee of the subject; b) the subject is i. the subject is selected as having good susceptibility to treatment if the biological sample from the subject contains CTX-II lower than 350±2SD ng / mmol, and / or ProC2 lower than 4.2±2SD ng / mL and JSW equal to or lower than 3.5±2SD mm; ii. the subject is selected as having intermediate sensitivity to the treatment if a biological sample from the subject contains CTX-II lower than 350±2 SD ng / mmol, and / or ProC2 lower than 4.2±2 SD ng / mL and JSW higher than 3.5±2 SD mm; or iii. The subject is selected as having intermediate sensitivity to treatment if the biological sample from the subject contains CTX-II greater than 350±2 SD ng / mmol and / or ProC2 greater than 4.2±2 SD ng / mL and JSW less than 3.5±2 SD mm; And c) Use in which subjects with good sensitivity are administered FGF-18 compound intra-articularly at a dose of 30-100 μg per administration, and subjects with moderate sensitivity are administered FGF-18 compound intra-articularly at a dose of about 100 μg per administration.

8. 8. The use according to claim 7, wherein the cartilage disorder is selected from the group consisting of osteoarthritis, cartilage injury, fractures affecting articular cartilage or surgical procedures affecting articular cartilage, and microfractures.

9. The use according to claim 7, wherein said FGF-18 compound comprises amino acid residues 28-196 of SEQ ID NO:1, optionally fused to a heterologous protein or chemical compound.

10. The use according to claim 7, wherein said FGF-18 compound is sprifermin or sprifermin fused to a heterologous protein or chemical compound.

11. The use of claim 7, wherein the FGF-18 compound is administered once a week for a three week treatment cycle.

12. The use according to claim 11, wherein the treatment cycle is repeated.

13. 1. Use of a means / agent for detecting CTX-II (C-terminal telopeptide of collagen type II) and / or ProC2 (neoepitope of collagen type II) and joint space width (JSW) in the manufacture of a kit for predicting sensitivity to treatment with an FGF-18 compound in a subject with cartilage damage, the kit comprising instructions for use, The kit comprises: a) determining from a sample from said subject the amount of at least one biomarker selected from the group consisting of CTX-II and ProC2; b) measuring JSW in at least one knee of the subject; and c) From the results of a) and b), i. good susceptibility to treatment if a biological sample from the subject contains CTX-II lower than 350±2SD ng / mmol, and / or ProC2 lower than 4.2±2SD ng / mL and JSW equal to or less than 3.5±2SD mm; or ii. intermediate sensitivity to treatment if a biological sample from the subject contains CTX-II lower than 350±2 SD ng / mmol and / or ProC2 lower than 4.2±2 SD ng / mL and JSW higher than 3.5±2 SD mm; or iii. intermediate sensitivity to treatment if a biological sample from the subject contains CTX-II greater than 350±2 SD ng / mmol and / or ProC2 greater than 4.2±2 SD ng / mL and JSW less than 3.5±2 SD mm; or iv. low sensitivity or insensitivity to treatment if CTX-II >350±2 SD ng / mmol and / or ProC2 >4.2±2 SD ng / mL and JSW >3.5±2 SD mm; Determine that; It is configured for wherein steps a) and b) are performed in any order.

14. 14. The use according to claim 13, wherein the cartilage disorder is selected from the group consisting of osteoarthritis, cartilage injury, fractures affecting articular cartilage or surgical procedures affecting articular cartilage, and microfractures.

15. The use according to claim 13, wherein said FGF-18 compound comprises amino acid residues 28-196 of SEQ ID NO:1, optionally fused to a heterologous protein or chemical compound.

16. The use according to claim 13, wherein said FGF-18 compound is sprifermin or sprifermin fused to a heterologous protein or chemical compound.

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